Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewPerioperative modifications of respiratory function.
Postoperative pulmonary complications contribute considerably to morbidity and mortality, especially after major thoracic or abdominal surgery. Clinically relevant pulmonary complications include the exacerbation of underlying chronic lung disease, bronchospasm, atelectasis, pneumonia and respiratory failure with prolonged mechanical ventilation. Risk factors for postoperative pulmonary complications include patient-related risk factors (e.g., chronic obstructive pulmonary disease (COPD), tobacco smoking and increasing age) as well as procedure-related risk factors (e.g., site of surgery, duration of surgery and general vs. regional anaesthesia). ⋯ Pulmonary function tests are not suitable as a general screen to assess risk of postoperative pulmonary complications. Strategies to reduce the risk of postoperative pulmonary complications include smoking cessation, inspiratory muscle training, optimising nutritional status and intra-operative strategies. Postoperative care should include lung expansion manoeuvres and adequate pain control.
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Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewManagement of mechanical ventilation during laparoscopic surgery.
Laparoscopy is widely used in the surgical treatment of a number of diseases. Its advantages are generally believed to lie on its minimal invasiveness, better cosmetic outcome and shorter length of hospital stay based on surgical expertise and state-of-the-art equipment. Thousands of laparoscopic surgical procedures performed safely prove that mechanical ventilation during anaesthesia for laparoscopy is well tolerated by a vast majority of patients. ⋯ The purpose of the review is to summarise the consequences of pneumoperitoneum on the standard monitoring of mechanical ventilation during anaesthesia and to discuss the rationale of using a protective ventilation strategy during laparoscopic surgery. The consequences of chest wall derangement occurring during pneumoperitoneum on airway pressure and central venous pressure, together with the role of end-tidal-CO2 monitoring are emphasised. Ventilatory and non-ventilatory strategies to protect the lung are discussed.
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Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewInfluence of non-ventilatory options on postoperative outcome.
Perioperative patient handling should urgently be updated according to current evidence and, if none is available, at least according to physiological knowledge. To prevent pulmonary aspiration, preoperative fasting for 2 h (clear fluids) and 6 h (solid food) and abdication of 20 min for smoking is sufficient. Beta-blockage requires an indication. ⋯ This strategy has been shown to positively influence organ function, homeostasis, morbidity, need for hospitalisation and convalescence and, therefore, to reduce costs. Despite these promising results, general implementation of evidence-based measures leaves a lot to be desired. Further development of surgical minimally invasive techniques and ongoing evaluation of procedure-specific strategies is urgently warranted.
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Best Pract Res Clin Anaesthesiol · Jun 2010
ReviewPrevention and reversal of lung collapse during the intra-operative period.
General anaesthesia induces ventilation/perfusion mismatch by lung collapse. Such lung collapse predisposes patients to preoperative complications since it can persist for several hours or days after surgery. Atelectasis can be partially prevented by using continuous positive airway pressure (CPAP) and/or by lowering FiO2 during anaesthesia induction. ⋯ The application of RMs during anaesthesia normalises lung function along the intraoperative period. There is physiological evidence that patients of all ages and any kind of surgery benefit from such an active intervention. The effect of RMs on patient outcome in the postoperative period is, however, not yet known.